Guía clínica para el manejo de la faringoamigdalitis aguda del adulto

Abstract

RESUMENLa faringoamigdalitis aguda (FAA) en el adulto es una de las enfermedades infecciosas más comunes en la consulta del médico de familia. La etiología más frecuente es viral. Dentro de la etiología bacteriana, el principal agente responsable es Streptococcus pyogenes o estreptococo β-hemolítico del grupo A (EBHGA), causante del 5-30% de los casos. En el manejo diagnóstico las escalas de valoración clínica, para predecir la posible etiología bacteriana, son una buena ayuda para seleccionar a qué pacientes se deben practicar las técnicas de detección rápida de antígeno estreptocócico. Es conocido que, en general, sin estas técnicas, se tiende al sobrediagnóstico de FAA estreptocócica, con la consiguiente prescripción innecesaria de antibióticos, muchas veces de amplio espectro. Así, con el manejo de las escalas y la técnica de diagnóstico rápido, elaboramos los algoritmos de manejo de la FAA. Los objetivos del tratamiento son acelerar la resolución de los síntomas, reducir el tiempo de contagio y prevenir las complicaciones supurativas locales y no supurativas. Los antibióticos de elección para el tratamiento de la FAA estreptocócica son penicilina y amoxicilina. La asociación de amoxicilina y clavulánico no está indicada en el tratamiento inicial en la infección aguda. Los macrólidos tampoco son un tratamiento de primera elección; su uso debe reservarse para pacientes con alergia a la penicilina. Es importante en nuestro país adecuar tanto el diagnóstico de la FAA bacteriana y la prescripción de antibióticos a la evidencia científica disponible. La implantación de protocolos de actuación en las farmacias comunitarias puede ser de utilidad para identificar y cribar los casos que no requieran tratamiento antibiótico. ABSTRACTThe acute pharyngotonsillitis (APT) in adults is one the most common infectious diseases in the family physician's surgery. The most frequent etiology is viral. Within the bacterial etiology, the main agent responsible is Streptococcus pyogenes or streptococcus β-GROUP A hemolytic (EBHGA), causing 5-30% of cases. In the diagnostic management, to predict the possible bacterial etiology, clinical evaluation scales are a good help for selecting which patients should undergo quick detection techniques for the streptococcic antigen. It is known that, in general, without these techniques streptococcic APT tends to be overdiagnosed, with the ensuing unnecessary prescription for antibiotics, often broad-spectrum. Thus, with the management of the steps and the quick diagnosis technique, we can draw up algorithms for managing APT. The objectives of the treatment are to accelerate the resolution of symptoms, reduce contagion time and prevent local suppurative and non-suppurative complications. The antibiotics of choice for treating streptococcic APT are penicillin and amoxicillin. The combination of amoxicillin and clavulanic acid is not indicated for the initial treatment of acute infection. Macrolides are not a first-choice treatment either; their use must be reserved for patients with allergy to pe...

Worldwide comparison of treatment guidelines for sore throat

“…Table 1 gives an overview of these guidelines by region and country; Figure 1 shows their origin on a world map. The highest number of guidelines were published in Europe; in addition to a European guideline, 23 a selection of the most recent and relevant published guidelines from Central (Germany), 24 Eastern (Russian Federation), 25 Northern (Netherlands 26 and Sweden 27 ), Southern (Italy 28 and Spain 29 ) and Western countries (France 30 and United Kingdom 31 ) were included. Of a large number, the most recent and relevant published guidelines were selected from North America, including Canada, 32 Mexico 33,34 and the USA 35‐37 .…”

“…Although 33 of the 36 guidelines provide recommendations regarding antibiotics, only 20 discuss other sore throat treatments. Of these 20 guidelines, 11 recommend paracetamol and non‐steroidal anti‐inflammatory drugs (NSAIDs) for the treatment of fever and pain, four recommend only NSAIDs, 32,46,29,25 one recommends only paracetamol 52 and one advises against the standard use of NSAIDs, because of their potential systemic side effects 26 . Furthermore, four guidelines recommend topical treatments such as lozenges, gargles or sprays for analgesic treatment 42,49,34,31 .…”

“…Eighteen of the 33 guidelines that give recommendations for antibiotics advise the duration of treatment. All indicate a 10‐day course of antibiotics, except the guidelines from France, Spain, the United Kingdom and China (Hong Kong), which recommend 6 days, 30 8‐10 days, 29 5‐10 days 31 and 5‐7 days of treatment, 8 respectively.…”

“…Furthermore, the appropriate duration of antibiotic therapy for streptococcal pharyngitis is controversial regarding clinical efficacy, bacteriological eradication and complication rates 74‐76 . Notwithstanding these considerations, many guidelines give no indication for the duration of antibiotics, and only few suggest a shorter treatment than the 10‐day standard regimen 29‐31,8 …”

The impact of rapid antigen detection test (RADT) for group A streptococcus on the antibiotic prescription: an observational study from a primary care setting in Lisbon

“…Above all, the results of this study suggest that performing RADT is especially important when the physician's interpretation based on clinical presentation is classified as diagnostic doubt or probably bacterial, as supported by different studies. 7,[12][13] Furthermore, most of the European guidelines for sore throat suggest that RADT should be performed if Centor Score or modified Centor Score ≥3 12 while others recommend RADT when Centor Score or modified Centor Score ≥2. 7,14 In addition, having a negative result on RADT can reassure the patient that antibiotics are not needed, thus decreasing the number of visits to healthcare facilities.…”